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People who reject or defer vaccination, even when life-saving immunisations are available, pose a growing problem in developing countries, the World Health Organization has warned.

In a collection of papers published in Vaccine this month (14 August), the UN body raises an alarm about what it calls “vaccine hesitancy” — a problem that has become more acute in the past decade. The WHO and UNICEF state that parental reluctance to vaccinate children could undermine health progress made as part of the Millennium Development Goals.

“Vaccine hesitancy has the connotation of being an issue in high-income countries only, but that’s clearly not the case.”

 Melanie Schuster, WHO

“Experiences from polio eradication programmes in India and Nigeria made it clear that vaccine hesitancy, public mistrust of vaccines and immunisation services, and outright rejection of vaccines are global issues that threaten to undermine decades of progress,” says the Vaccine editorial.

Every year around 1.5 million children die of diseases that could be prevented by existing vaccines, the WHO says. But it is hard to know how many of these deaths are due to vaccines being hard to access in the first place, rather than to hesitant parents, says Melanie Schuster, the WHO’s medical officer for immunisation, vaccines and biologicals in Switzerland.

Out of 180 countries that filled a WHO/UNICEF joint reporting form last year, 131 provided at least one reason for patients refusing vaccines according to their country’s immunisation schedule. “Vaccine hesitancy has the connotation of being an issue in high-income countries only, but that’s clearly not the case,” Schuster says.

The collection of Vaccine articles lists three broad reasons why people refuse or delay vaccination: confidence, complacency and convenience.

Lack of confidence happens when people doubt that a vaccine is safe or effective, or mistrust the health services that deliver it. “In some rural communities in East Africa or South-East Asia, you find fears that vaccines are dangerous and could cause infertility,” says Noni MacDonald, a paediatrics professor at Dalhousie University in Halifax, Canada, who co-authored several papers in the Vaccine series.

Complacency means that people give priority to other things that are more important to them than vaccination, such as subsistence farming, adds MacDonald, who is also co-director of MicroResearch, a Canadian programme that supports healthcare professionals in East Africa.

Convenience is another important factor driving vaccine hesitancy — and is a problem when health services are expensive or hard to access. To help counter this issue in the Democratic Republic of Congo, for example, the medical charity Médecins Sans Frontières tries to bring measles vaccination services closer to people’s homes, says Kate Elder, vaccines policy advisor for MSF’s Access campaign in New York, United States.

“If a 4x4 [vehicle] is not enough, we use motorcycles or boats sometimes,” she says.

Manufacturers could also play their part in making vaccines more convenient, adds Elder. They could lower their products’ prices, improve formulas and deliveries, and make vaccinations less arduous for children by combining different vaccines in one injection. But because there is a wide range of reasons behind vaccine hesitancy, those in charge of immunisation campaigns may have the wrong ideas about what the problems and answers are, MacDonald says.

She mentions the example of a recent measles outbreak among the Roma population in Bulgaria. In this particular case, Roma mothers were reluctant to attend the clinic because they found that healthcare workers there treated them disrespectfully.

“There aren't simple solutions to this complex problem, so it’s important to determine who is hesitant, and make the diagnosis about what the real problems are,” MacDonald says.

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